Abstract

BACKGROUND. Attention-deficit/hyperactivity disorder, the most common childhood behavioral condition, is one that pediatricians think they should identify and treat/manage.

OBJECTIVE. Our goals were to explore the relationships between pediatricians' self-reports of their practice behaviors concerning usually inquiring about and treating/managing attention-deficit/hyperactivity disorder and (1) attitudes regarding perceived responsibility for attention-deficit/hyperactivity disorder and (2) personal and practice characteristics.

METHODS. We analyzed data from the 59th Periodic Survey of the American Academy of Pediatrics for the 447 respondents who practice exclusively in general pediatrics. Bivariate and logistic regression analyses were used to identify attitudes and personal and practice characteristics associated with usually identifying and treating/managing attention-deficit/hyperactivity disorder.

RESULTS. A total of 67% reported that they usually inquire about and 65% reported that they usually treat/manage attention-deficit/hyperactivity disorder. Factors positively associated with usually inquiring about attention-deficit/hyperactivity disorder in adjusted multivariable analyses include perceived high prevalence among current patients, attendance at a lecture/conference on child mental health in the past 2 years, having patients who are assigned or can select a specific pediatrician, practicing in suburban communities, practicing for ≥10 years, and being female. Pediatricians' attitudes about responsibility for identification of attention-deficit/hyperactivity disorder were not associated with usually inquiring about attention-deficit/hyperactivity disorder in either unadjusted or adjusted analyses. Attitudes about treating/managing attention-deficit/hyperactivity disorder were significantly associated with usually treating/managing attention-deficit/hyperactivity disorder in unadjusted and adjusted analyses. Those who perceived that pediatricians should be responsible for treating/managing had almost 12 times the odds of reporting treating/managing attention-deficit/hyperactivity disorder, whereas those who believe physicians should refer had threefold decreased odds of treating/managing. Other physician/practice characteristics significantly associated with the odds of usually treating/managing attention-deficit/hyperactivity disorder include belief that attention-deficit/hyperactivity disorder is very prevalent among current patients, seeing patients who are assigned or can select a specific pediatrician, and practice location.

CONCLUSIONS. Taking responsibility for treating attention-deficit/hyperactivity disorder and practice characteristics seem to be important correlates of pediatrician self-reported behavior toward caring for children with attention-deficit/hyperactivity disorder.

Attention-deficit/hyperactivity disorder (ADHD) is the most common childhood behavioral issue1 and is frequently treated in pediatric primary care settings.2 It affects 8% to 12% of children across many countries.3,4 A recent population-based study documents that parents of 8.8% of US children 6 to 17 years report that a health professional told them that their child has ADHD.5 Thus, it is a problem that affects substantial numbers of patients in the average practice and often persists into adulthood.3

Beyond its prevalence, efficacious and safe treatments exist for ADHD.6,7 Based on a review of the evidence, the American Academy of Pediatrics (AAP) undertook and published guidelines for the recognition (2000) and treatment (2001) of ADHD.8,9 Subsequently, together with National Initiative for Children's Healthcare Quality and the North Carolina Center for Children's Health care Improvement, the AAP prepared and broadly disseminated a toolkit designed for use in primary care pediatrics.10 The toolkit included protocols for recognition and accurate diagnoses and treatment. The AAP undertook an educational campaign targeted to practicing clinicians. Thus, ADHD has been addressed in a more focused effort in pediatrics than any other common behavioral or mental health disorder.

We previously reported large differences in pediatricians' perception of their responsibility toward treating/managing ADHD compared with other behavioral issues.11 In view of the large differences in pediatricians' attitudes and the extensive campaign by the AAP to educate pediatricians about ADHD, we sought to examine attitudes and reported practices regarding identification and treatment/management for ADHD. We also sought to assess personal and practice characteristics associated with caring for children with ADHD and whether pediatricians' reports of their own practice behavior toward inquiring about and treating/managing ADHD differs according to their: (1) attitudes toward the pediatrician's perceived responsibility for ADHD; and (2) their personal and practice characteristics.

METHODS

Design/Methods

Data were obtained from the 59th Periodic Survey conducted by the AAP, representing an estimated 80% of the 50818 nonretired board-certified pediatricians in the United States. Since 1987, AAP Periodic Surveys have been administered 3 to 4 times annually to random samples of members to assess their attitudes and practices. Surveys are pretested and approved by the AAP Institutional Review Board. Survey details, which included questions on pediatrician's attitudes about behavioral issues and barriers to providing care for these issues, have been reported elsewhere.12

An initial mailing with up to 5 mailings to nonrespondents was sent to 1600 randomly selected members between March and August of 2004. This was considerably after the publishing of the guidelines, but before the widespread dissemination of the toolkit. Among the 1294 nontrainee members, 57% responded (N = 745). Bivariate comparisons of responders and nonresponders for all members surveyed show that women and older members were significantly more likely to respond. To correct potential biases that might result, poststratification sample weights were developed. Multivariable logistic regression models were used to estimate the probability of response; the final model included age group (≥40 vs <40), gender, and the 2-way interaction between age and gender. The sample weights were rescaled such that the mean was unity and the sum was equal to the analytic sample size: men <40 years of age: 1.28; men 40 years of age: 1.10; women <40 years of age: 0.93; women ≥40 years of age: 0.87.

The 8-page survey contained fixed-response questions including sociodemographic, background education, and practice characteristics, and questions about perceived responsibility toward identifying, treating, and referring children with 7 different mental health conditions that are amenable to behavioral and/or pharmacologic interventions, including ADHD. Respondents were asked how prevalent ADHD was among their current patients (slightly/not at all, moderately, extremely/very, or don't know) and how much effect it had on both child's physical and mental health (little/none, moderate, or extreme/great). They were also asked whether they agreed, disagreed, or were neutral about the statement that pediatricians should be responsible for (a) identifying, (b) treating or managing, and (c) for referring ADHD. Finally, they were asked in their practice how frequently they inquired about, treated/managed, and referred children with ADHD (usually, sometimes, or never). After reviewing the 3 category results, sometimes and never were combined and 3 binary variables were created indicating whether the physician usually inquired about, treated/managed, or referred ADHD.

Background and practice characteristics were tabulated. Because a number of subspecialty areas emphasize behavioral issues, we classified respondents who completed a fellowship in a child mental health related area (behavioral/developmental pediatrics, child psychiatry, adolescent medicine and/or behavioral sciences) as having additional child mental health fellowship training.

For this report, we limited the sample to the 447 respondents who indicated that their entire practice was devoted to general pediatrics, currently see patients, and who completed the attitude and behavior questions.

Analyses

Weighted means and SDs were used to describe continuous measures, and unweighted counts and weighted proportions were used to summarize categorical measures. Using the weighted sample, responses for the self-reported behaviors, including whether they usually inquired about, treated/managed, or referred children with ADHD were examined. The Rao-Scott χ2 test and weighted logistic regression analyses were used to assess bivariate associations between usual behavior regarding identification and treatment/management of ADHD and (1) attitudes about responsibility for identifying, treating/managing, and referring ADHD; and (2) physician and practice characteristics. Covariates with bivariate associations significant at P < .15, as well as variables of clinical interest (eg, additional child mental health fellowship training) were further explored by using weighted multivariable logistic regression analyses. Main effects models were fitted and covariates were retained if statistically significant at P < .05. The odds ratios and 95% confidence intervals are presented. Analyses were performed in SAS 9.1.3 (SAS Institute, Inc, Cary, NC) by using procedures appropriate for survey data.

RESULTS

The characteristics of the pediatricians practicing exclusively as general pediatricians are described Table 1. More than half were women; nearly 70% the sample was <50 years old and 72% were white. Approximately half practiced in suburban areas, and the rest were evenly split among urban inner city, urban non–inner city, and rural. The most common practice mode was group practice (50%), and more than half reported seeing ≥100 patients per week. As many as 107 (23%) said that they had additional child mental health fellowship training, but most occurred ≥10 years earlier.

Table 2 summarizes responses for the questions about attitudes and usual behavior regarding ADHD. Although 91% agreed that pediatricians should identify children with ADHD, only 67% reported they usually inquire about it in their practices. In contrast, 71% thought that it was the pediatrician's responsibility to treat/manage ADHD, and 65% reported they usually treat/manage ADHD.11 Although 53% responded that pediatricians should be responsible for referring ADHD,11 only (28%) reported they usually refer children with ADHD. Overall, 87.2% reported they either usually treat/manage and/or they usually refer ADHD; thus, 12.8% report they neither usually refer nor treat/manage ADHD.

Although attitudes about responsibility for identifying ADHD were not significantly associated with inquiring about ADHD, attitudes regarding responsibility for treating/managing and referring for ADHD were positively associated with treating/managing ADHD (Table 3). Over 80% of those who agree that pediatricians should be responsible for treating/managing ADHD reported usually treating/managing ADHD; only 25% who were neutral and 7% who disagreed that pediatricians should be responsible for treating/managing ADHD reported usually treating/managing this condition. Similarly, attitudes regarding referring were negatively associated with treating/managing ADHD. Fewer than half the respondents who agreed that pediatricians should be responsible for referring for ADHD reported usually treating/managing this condition, whereas >80% of those who were neutral or disagreed reported usually treating/managing ADHD. Pediatricians who believe that ADHD is very prevalent among their current patients more often reported usually inquiring about and usually treating/managing ADHD. Although believing that ADHD has an extreme effect on children's physical and mental health was significantly associated with usually inquiring about ADHD, neither was significantly associated with treating/managing ADHD.

Bivariate associations between physician/practice characteristics and self-reported behaviors regarding inquiring about and treating/managing of ADHD are shown in Table 4. A greater proportion of physicians who reported usually inquiring about ADHD were women, but similar proportions of men and women reported usually treating/managing ADHD. Physicians in practice for longer more often reported they usually inquire about ADHD and those in practice for ≥5 years more often reported treating/managing ADHD. Pediatricians in suburban practices more often reported they usually inquire about ADHD, whereas those in urban inner-city practice settings less often reported usually treating/managing ADHD. Pediatricians who see predominantly white patients more often reported usually treating/managing ADHD. A greater proportion of pediatricians who reported usually inquiring about and treating/managing ADHD reported that their patients are either assigned to or can select a specific pediatrician as their physician. Attendance at a lecture/conference on child mental health in the past 2 years and interest in additional education in treatment/management of child mental health issues were positively associated with usually inquiring about and treating ADHD. However, having additional child mental health fellowship training, the number of ambulatory visits per week, patient insurance, and availability of child mental health services were not significantly associated with inquiring about or treating/managing ADHD.

The results of the multivariable logistic regression model investigating the features related to usually inquiring about ADHD are shown in Table 5. As in the bivariate analysis, pediatricians who believe that ADHD is very prevalent among their current patients, attended a lecture/conference on child mental health in the past 2 years, and see patients who are either assigned or can select a pediatrician as their physician had nearly twice the odds of reporting usually inquiring about ADHD. Female physicians, those who have been in practice for ≥10 years and who practice in suburban areas (versus rural locations or urban non–inner-city areas), also had significantly higher odds of usually inquiring about ADHD. Because attitude about responsibility for identification of ADHD was not statistically significant, it was omitted from the final model.

The weighted multivariable logistic regression model investigating factors related to treating/managing ADHD is presented in Table 6. Respondents who agreed pediatricians should be responsible for treating/managing ADHD had 12-times greater odds of reporting treating/managing ADHD, whereas those who agreed that pediatricians should refer children with ADHD had more than threefold decreased odds of reporting that they usually treat/manage ADHD. Respondents who believe that ADHD is very prevalent among their current patients and who reported that their patients are either assigned or could select a specific pediatrician as their physician had more than twice the odds of usually treating/managing ADHD. Compared with pediatricians practicing in urban inner-city settings, those practicing in either suburban or rural areas were at increased odds of reporting usually treating/managing ADHD.

DISCUSSION

Our findings suggest distinct patterns that are associated with usually inquiring about and treating/managing children with ADHD. Attitudes regarding responsibility for identifying ADHD were not significantly associated with self-reported behavior of usually inquiring about ADHD. However, attitudes regarding responsibility for treatment/management and referring for ADHD were associated with self-reported behaviors of usually treating/managing ADHD. Beliefs about ADHD prevalence among current patients were positively associated with both inquiring about and treating/managing ADHD. Strikingly, continuity of care (patients are assigned or can select a pediatrician as their physician) was significantly associated with both usually inquiring about and treating/managing ADHD, adjusting for other confounders.

Location of practice was significantly associated with usually inquiring about and treating/managing ADHD, but the pattern differed for the 2 outcomes. Physicians who practice in suburban locations had higher odds of inquiring about ADHD, whereas physicians practicing in urban inner-city areas had lower odds of treating/managing ADHD. The finding that urban inner-city pediatricians had the lowest odds of reporting that they treat/manage ADHD has potential implications for overcoming the reported under-treatment of urban children with this condition.13 Under recognition and treatment among minority children are factors that have often been attributed to the attitudes of minority inner-city families13 rather than to professional behavior.

It is unclear whether high perceived prevalence in practice and the higher level of attendance at a child mental health lecture/conference are causes or consequences of usually inquiring and treating/managing. It may be that recognition of the needs of patients in the practice leads to attendance at continuing education programs, or alternatively that attendance leads to recognition of the needs of patients. As Leslie et al14 notes: “education alone does not change practitioner behavior, but serves a preparatory function of educating providers regarding the need to change.” Once pediatricians become more aware of a problem, it is likely that they will pay more attention to it and over time may learn to address it.

As expected, the association between usually inquiring and usually treating/managing ADHD was statistically significant. Those who reported usually inquiring about ADHD more often reported usually treating/managing ADHD (72% vs 51%; P < .0001). We chose to model each outcome separately as the physician and practice characteristics related to inquiring about and treating/managing ADHD could, and in fact did, differ, but not surprisingly several of the physician/practice characteristics are significantly associated with both outcomes. We have previously reported a lack of systematic differences in perceived barriers to the delivery of mental health services by practice location.12 We expected that a significant bivariate association of additional fellowship training would be associated with inquiring about and treating/managing ADHD and were surprised to find that this was not the case. This may reflect inclusion of only those who currently practice general pediatrics in the analyses. Nevertheless, this finding is somewhat surprising. It may also reflect that until recently there was no standardization of fellowship training in Developmental/Behavioral Pediatrics. Also, ADHD was not a focus of attention within adolescent medicine, because there was less appreciation of the duration of functional impairment and developmental disabilities fellowships may not have focused on ADHD. As mentioned earlier, most fellowship training had been completed ≥10 years earlier. Alternatively, it may be that additional training heightened awareness of the complexities of diagnosing and treating the condition and increased reluctance to do so.

There are several important limitations to this report. First, it is a self-report of pediatricians' attitudes and behaviors that relies on data collected from an incomplete sample using a fixed-response format. Because the survey focused broadly on behavioral health, not specifically on ADHD, no questions directly probed exposures expected to alter physician's attitudes toward ADHD, such as the AAP campaign or continuing education efforts. Nor do we know the extent to which the availability and detailing of pharmacologic treatments might have influenced pediatrician attitudes and behaviors.

Second, given the large proportion of respondents who reported additional child mental health fellowship training, we suspect that respondents had greater interest in the mental health issues than those who chose not to respond. Thus, response bias is likely to be in the direction of reporting more willingness to inquire about, treat, and refer ADHD than might be expected from the full target sample. Respondents may also be biased in reporting their behavior as more positive than it is likely to be found by direct examination.15 In addition, even if the pediatricians report their behavior accurately, the diagnosis may not be made correctly and treatment may not follow recommended ADHD guidelines. Shortly after the guidelines were released, Rushton et al16 found that although 91.5% of responding pediatricians in Michigan were familiar with the AAP guidelines for ADHD, only 78% read and incorporated them into their practices, and only 34.9% of respondents used all 4 diagnostic components in their practice. This is consistent with national findings from the mid-1990s that clinicians were not using scales and criteria to make the diagnosis.17 This is a problem, especially if respondents tend to be those more positively inclined toward the survey topic and if, as Leslie et al14 found, only 44% of consecutively enrolled children with school and behavioral problems meet criteria for ADHD on both parent and teacher scales, but many had other mental health and learning problems. This underscores the complexities facing the clinician.

In addition, even if the diagnostic criteria are met, the treatment recommendations may not be followed. Although the majority of pediatricians do use medications and titrate them in the first month,16only 41.6% evaluate them 3 to 4 times per year as recommended.16 In addition, the Multimodal Treatment Study of Children with ADHD documents that even when the diagnosis is made correctly, treatment given in the community is not always given at effective doses, resulting in poorer performance of subjects in the community treatment arm of the study than in the protocolized medication arm.16 Thus, although in our national sample 65% of pediatricians say they are usually treating/managing ADHD, this does not necessarily translate into correct diagnosis and optimal treatment.

Despite these limitations, the patterns found here suggest some specific areas of practice management that may be important for attempts to increase pediatricians' identification and treatment of children with ADHD. Key areas may be promoting continuity relationships with individual children and assessing what the factors make it more likely for pediatricians in some settings to treat children with ADHD than in others. More work is needed before to ensure that children and adolescents with this common condition are receiving state-of-the-art care for it.

We speculate that the results also lend support to the important role of having a professional organization promote the diffusion of innovation into practice by writing and disseminating clear guidelines. Although the toolkit was not available until about the time of the survey, the AAP had mounted an effective campaign to promote the notion that identification and treatment of ADHD was in the purview of primary care pediatricians. We believe that when a prominent professional organization creates the expectation that care of patients with a certain condition should be a professional's responsibility and provides resources to support the execution of that responsibility, it can affect an important overall change in the pattern of those in the profession and influence their self-reported behavior in taking on this responsibility.

Acknowledgments

This research was funded by the Annie E. Casey Foundation. We thank them for their support but acknowledge that the findings and conclusions presented in this article are those of the authors alone, and do not necessarily reflect the opinions of the foundation.

We also thank Dr Mark Wolraich for review of the manuscript and helpful comments.

The authors have indicated they have no financial relationships relevant to this article to disclose.

What's Known on This Subject

ADHD is a common behavioral issue, and the AAP has advocated that pediatricians should identify and treat/manage it, but little is known about whether general pediatricians support these ideas.

What This Study Adds

These national data show that pediatricians overwhelmingly think they should be responsible for identifying and treating/managing ADHD, but only 48% report usually both inquiring about and treating/managing it. The study also identifies factors that are associated with doing so.

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